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I read with great interest the study by Domanski et al. (1)on diuretic use and outcome of heart failure. The first question that comes to mind is whether patients taking non–potassium-sparing diuretics (PSDs) were sicker than patients taking PSDs considering the weak diuretic action of PSDs. The fact that 25% of patients in the PSDs-only group were receiving beta-blockers is indicative of a relatively “healthy” group. Thus, it might have been appropriate to exclude these patients from study. In the multivariate analysis, the investigators should consider including two variables indicative of the severity of heart failure, namely elevated jugular venous distention and a third heart sound. These two clinical signs have previously been found in the Studies Of Left Ventricular Dysfunction (SOLVD) to be independently associated with adverse outcome (2).

Thus, the issue of confounding by the severity of heart failure could be more adequately addressed by providing data on jugular venous distention and a third heart sound and including them in the multivariate analysis.

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